Medication Reconciliation Guidelines

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Medication Reconciliation Guidelines

Terms:
AMROF: Admission medication reconciliation form
DMROF: Discharge medication reconciliation form
RXM: The medication prescribing program in meditech
Patient Home Medication List: The medication list generated from the RXM database for patients at d/c

Admission Medication Reconciliation

  1. On presentation to the emergency room, the ER nurse is responsible for editing the medications in RXM so that you have an accurate list when you come to admit the patient. This is a process that’s supposed to happen on every admitted patient but it should be recognized that this is done with variable consistency.
  2. When you see the patient, go into RXM, click on “current medication list” and review it for accuracy. IMPORTANT: YOU SHOULD NOT ASSUME THIS IS A FULLY ACCURATE MEDICATION LIST! You must review it carefully for errors!! This list is a combination of old prescriptions built up over the past year that may or may not have been fully edited by by the ER nurse, as well as medications added by the ER nurse at triage. If a medication has a doctor’s name next to it, that usually means it was prescribed at some point. If it says “reported” that means it was just listed by a provider (usually the ER nurse)
  3. If any changes are made to the RXM list, you do it in the computer before you print out the AMROF. (Helpful tip—if you want to add a medication in RXM without writing a prescription, click “update medication list”) Again, all changes should be made in the computer before you print out the list – handwritten modifications are no longer acceptable.
  4. Print out the AMROF. The way you should think about his order form is that the left side represents your best judgment as to what the patient is taking on admission and should basically be identical to the list you would write on the H & P. On the right side you indicate continue/discontinue/modify – essentially you are telling the pharmacy what to dispense to the patient on admission.
  5. A good rule of thumb is that when in doubt about the accuracy of a medication, do not continue it on admission.
  6. If there are no medications in RXM, the computer program will not allow you to print out the AMROF. If this happens, you need to “prescribe” the medication “none”. This will then allow you to print out the AMROF. All patients must have a computer generated AMROF, even if they are not taking any medications.
  7. If the patient is directly admitted, then you must edit the RXM list without a nurse’s help and print out the AMROF as described above. Patients admitted postoperatively are supposed to have their RXM lists edited by the preop nurse, so presumably this should be a reasonably accurate list.
  8. Now, if you want to review the patient’s outpatient meds during the hospitalization, you simply go to RXM and click on “current medication list.” This list should now be complete and accurate.

Discharge/Transfer Medication Reconciliation

  1. For standard discharges to home/board&care/SNF, do the following:
    1. In meditech under “Medication Reconciliation Forms” print out the report titled “DC: Med/Surg to home/SNF”
    2. This report takes the meds listed in RXM and lists them as “Home Medications” and lists them next to the “Inpatient Medications”
    3. If you want to continue or modify a medication, check the appropriate box. Meds in which the box is not checked means that you have discontinued the medication. Think about this form as a “worksheet” to help you figure out what the patients’ discharge meds should be.
    4. Go into RXM, write new prescriptions as needed, and d/c medications from the “current medication list” you do not want patient to continue after discharge. This list should now reflect the patients’ medications at discharge.
    5. Go to the “print” tab in RXM and print “active med list”. This is the “Patient Home Medication List” for the patient to review.
    6. IMPORTANT: On the last page of the patient friendly medication list, it says “STOP THESE MEDICINES:” You must write the medications you discontinued from the RXM list in this area. This is the way you indicate to the patient that they must stop a medication that they were previously taking prior to admission.
    7. On followup visit to the outpatient provider, the RXM medication list will now be fully updated for review and generating further prescriptions.

  1. If you are sending a patient to another hospital, do the following:
    1. In Meditech under “Medication Order Forms” print out the report “DC: Other Hospital”
    2. Indicate continue/discontinue/modify, sign the bottom.
    3. You do not need to reconcile the patient’s home medications, nor do you need to print out a “Patient Home Medication List”
    4. If a patient is expected to return to CCRMC after a procedure (e.g. cardiac cath) this form does not need to be filled out

  1. If you are discharging a patient to psych or admitting a patient from psych to medicine, do the following:
    1. In Meditech under “Medication Order Forms” print out the report “DC/ADM to/from Med/Psych”
    2. Indicate continue/discontinue/modify, sign the bottom
    3. You do not need to reconcile the patient’s home medications, nor do you need to print out a “Patient Home Medication List”

  1. If you are transferring a patient to or from IMCU/ICU or writing postop orders on already admitted patients, do the following:
    1. In Meditech under “Medication Order Forms” print out the report “Transfer MROF”
    2. Indicate continue/discontinue/modify, sign the bottom

If you have questions, PLEASE CONTACT THE FOLLOWING PROVIDERS TO ASSIST WITH THE MEDICATION RECONCILIATION PROCESS:
Dana Colomb, RN x 5780
Pharmacy 4018
Discharge nurse (Constance Pasion) pager 269
Terri Horvath pager 042 x5778

Thanks for you help and support. This is going to be really great, I promise.
Oliver Graham, Pager 995
Updated 7/14/09






This page has been edited 3 times. The last modification was made by - oliverzgraham oliverzgraham on May 27, 2010 10:48 am